Cosmetic Dermatology Treatment Plan and Guidelines

Patient Information

• Name: _________________________
• Date: _________________________
• Provider: ______________________

Selected Treatment Areas

• Face/Neck
• Hands
• Chest/Décolletage
• Other: ______________________

Recommended Procedures

Primary Treatments

1. Injectable Treatments

   • Botulinum toxin (Areas: ______________)
   • Dermal fillers (Type: ______________)

2. Laser Procedures

   • Fractional laser resurfacing
   • IPL photofacial
   • Laser hair removal

3. Chemical Treatments

   • Chemical peel (Strength: ______________)
   • Microdermabrasion

Treatment Schedule

Pre-Treatment Instructions

1. Avoid sun exposure for 2 weeks prior
2. Discontinue retinoids 5-7 days before treatment
3. No aspirin or blood thinners 1 week prior (with physician approval)
4. Arrive with clean, makeup-free skin

Post-Treatment Care

• Apply sunscreen SPF 30+ daily
• Avoid direct sun exposure for ____ days
• Use prescribed skincare products as directed
• Contact office if experiencing unusual symptoms

Follow-up Plan

Scheduled review in _____ weeks

Emergency Contact

Clinic Phone: ________________ After Hours: ________________

Acknowledgment

I understand the proposed treatment plan and agree to follow the care instructions.

Patient Signature: _________________ Date: _________